Salon 1 15 kasim 09.30 10.30 eunok kwon

1. Unplanned extubation of patients in ICU
Eunok Kwon, RN, PhD
Nursing Director of Operating room,
Seoul national University Hospital, South Korea
10th International Congress of World Federation of Critical Care Nurses,
Antalya, Turkey , November 12~ 15th 2014.

2. Safety Issues in ICU
• More than 5 million patients are admitted to intensive
care units each year in the United States.
• Mortality rates in patients admitted to the ICU average
10% to 20% in most hospitals.
• Overall, approximately 200,000 patients die in U.S.ICU
each year.

3. Safety issues in ICU
Classification of incidents used in the Australian AIMS
• Airway and ventilation: e.g. unplanned extubation and
disconnections.
• Drugs and medications: e.g. allergic reactions and drug
errors.
• Procedures, equipment and catheters: e.g. inadvertent
carotid artery cannulation.
• Patient environment: e.g. a lack of appropriate beds
causing pressure sores.
• ICU management: e.g. incidents caused by an over reliance
on agency staff.

4. Patient’s outcome indicators in ICU
( European Society of Intensive Care Medicine)
Domain Description Consensus (%)
Structure Intensive Care Unit (ICU) fulfills national requirements to
provide Intensive Care.
100
24-h availability of a consultant level Intensivist 94
Adverse event reporting system 100
Process Presence of routine multi-disciplinary clinical ward rounds 100
Standardized Handover procedure for discharging patients 100
The maintenance of continuing medical education according to
77
national standards
The maintenance of bed occupancy rates below a threshold level. 82
Outcome Reporting and analysis of standardized mortality ratio (SMR) 100
ICU re-admission rate within 48 h of ICU discharge 94
The rate of central venous catheter-related blood stream
infection
100
The rate of unplanned endotracheal extubations 100
The endotracheal re-intubation rate within 48 h of a planned
77
extubation
The rate of ventilator-associated pneumonia 77

5. Factors related to safety issues
in ICU
INTENSIVE CARE SOCIETY STANDARDS © 2005

7. Therapeutic catheters in ICU
• Types of catheters;
Foley catheter(75%), Central venous
catheter(64%), Endotracheal catheter (62%),
Arterial line(44%) Chest tibe(14%)
• 1995,European Prevalence of Infection in
Intensive Care (EPIC) study; Catheter related
infection & hospital acquired infection,
Unplanned extubation results in fetal patient’s
outcome.

8. Accidental removal of catheter threatens patient’s safety

9. Importance of management catheters
• Complication of accidental removal of catheters
• Intraventricular brain drainage ; hydrocephalus
• Cardiac surgical drainage; cardiac tamponade
• Subclavian or jugular venous catheter reinsertion;
pneumothorax and/or hemothorax.
• Endotracheal reintubation ; nosocomial pneumonia,
• New drains reinsertion; hemorrhage or nosocomial
infection.

10. Prevention of Unplanned
extubation in ICU

11. Unplanned endotracheal extubations in ICU
 Unplanned extubation rate; 0.1~3.6/100 intubation days.
 Risk factors;
 male gender, APACHE score≥ 17(OR9.0), COPD,
restlessness/agitation(OR3.3-30.6),
 lower sedation level(OR2.0-5.4),
 Higher consciousness level(OR 1.4-2.0),
 Use of physical restrains (OR3.1).
 Reintubation rates 1.8-88% of unplanned extubation.
 Preventive measures; Standardization of procedures,
staff education, staff surveillance & identification &
management of high risk patients -
decreasing rate; 22~53%
 Best methods; securing E tube & use of Physical
restraints ??

12. Nurse staffing factors related patient
outcomes in ICU
• 28 research RN-to patient ratio vs patient outcome odds
ratio
• RN staffing ratio vs ICU mortality OR 0.91(95%Cl)0.86-
0.96 surgical 0.84 medical 0.94
• Increase by 1RN per patient day decreased VAP OR
0.7(95%Cl 0.56-0.88) unplanned extubation
(OR,0.49;95%Cl),respiratory failure(0.40;95%Cl), cardiac
arrest in ICU(OR 0.72;95%Cl),lower risk of failure to
rescue in surgical patients(OR0.84;95%Cl), Length of stay
was shorter by 24% in ICUs(OR 0.76;95Cl)& 31% in surgical
patients(OR,0.69;95%Cl)
• The association of registered nurse staffing levels and patient oucomes;Med care.2007
Dec;45(12)1195-204 Kane RL et al

13. Safety model related to unplanned extubation in ICU ;
SEIPS model(Carayon et al.2006)

14. Introduction- Critical care unit in
SNUH
MICU
22 bed
SICU1
18bed
CPICU
8 bed
SICU2
14bed
CCU
8 bed
EICU
12 bed
Adult ICU;
70 bed
NICU
40bed
PICU
20bed
1821 total hospital
beds,
154 ICU Beds
Emergency center
Children’s
Hospital

15. Nurse Staffing
Nurse to patient ratio=
1:2

16. Case; SNUH adult ICU
• A case-control study over 3 years period from
January 1,2010 through December 31,2012.
• A 62-beds medical & surgical intensive care unit
of 1800 beds tertiary hospital

17. Unplanned VS planned extubation Patients
• Data were retrospectively
collected from electronic
medical records.
• A total 230 episodes of
deliberate unplanned
extubation in 242 patients
from 41,207 mechanically
ventilated patients for 3
years(frequency 0.53%).
• 460 episodes in 460
patients with planned
extubation age, gender &
diagnosis-matched controls
were analyzed in this
case-control study.

18. Predictors related to unplanned extubation
in SNUH cases
Predictors associated with unplanned extubation
include
•Better motor response (OR 1.3),
•Admission route via ER(OR 1.8),
•Higher APACHE Ⅱscore(1.061),
•Mode of mechanical ventilation (CPAP, PSV: OR4.1,
SIMV:3.0),
•Peripheral O2 saturation(OR:0.9), heart rate(OR:
1.0), respiration rate(OR:1.0)

19. Predictors related to unplanned
extubation in SNUH cases
• Pain (OR:0.3),
• Agitation(OR:9.0),
• Delirium(OR:11.6),
• Night shift(OR:6.0)
&morning care
time(OR:0.5).

20. Predictors related to unplanned extubation
in SNUH cases
The patients’ & organizational outcomes of
unplanned extubation were
•Reintubation(OR;85.66)
•Poor discharge result(OR:0.2)
•Longer length of stay in the ICU (adj R-square:
7%)and a longer length of stay in the
hospital(adj R-square:4.3%).

21. High predictive factors of unplanned
extubation in SNUH cases
• Delirium, agitation, ventilation mode and night shift are
high predictive factors of unplanned extubation.
• The outcomes of unplanned extubation were
increasing reintubation, a poor patient outcome
at the time of discharge and poor
organizational outcome including longer length
of stay in the ICU and hospital.

22. SICU

23. Safety issues of Adult ICU patients in SNUH

24. PAD concept of SNUH ICU

25. Delirium management in SNUH ICU
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vveennttiillaattoorr
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mmoorrttaalliittyy &&
mmeeddiiccaall
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ssaattiissffaaccttiioonn
ooff ccaarreeggiivveerr
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lleennggtthh ooff
ssttaayy

26. PAD management in SNUH ICU
DDeelliirriiuumm mmaannaaggeemmeenntt
pprroottooccooll ffoorr hhiigghh rriisskk
ggrroouupp ooff ddeelliirriiuumm
DDeelliirriiuumm mmaannaaggeemmeenntt
pprroottooccooll ffoorr hhiigghh rriisskk
ggrroouupp ooff ddeelliirriiuumm
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Age>65
Age>65
Visual acuity
defect, hearing
disturbance
Cognitive function
Visual acuity
defect, hearing
disturbance
Cognitive function
impairment
Restraint
impairment
Restraint
DDeelliirriiuumm
mmaannaaggeemmeenntt
pprroottooccooll
DDeelliirriiuumm
mmaannaaggeemmeenntt
pprroottooccooll
2012 ICU QA
outcome indicator
Accidental
catheter removal
rate,
Delirium
incidence.

27. Establishing monitoring system of
Delirium in Adult ICU; CAM ICU

28. AACCRR,, DDeelliirriiuumm ooccccuurrrreennccee
rraattee 22001122yyrr
((11..44%%))
((11..22%%))

29. 2013 PAD care bundle of ICU in SNUH
iPAD(ICU Pain, Agitation, Delirium) Care Bundle
PAIN AGITATION DELIRIUM
ASSESS
Assess pain ≥ 2/shift
Patient able to self-report
→ NRS (0-10)
Unable to self-report
→ CNPS (0-9)
Assess agitation,
sedation ≥ 2/shift
RASS (-5 to +4)
Assess delirium Q shift
CAM-ICU (+ or -)
Delirium present if CAM-ICU
is positive
TREAT
Treat pain with
analgesia therapy
Targeted sedation: RASS
-2 to 0(light sedation)
Treat with sedatives for
light sedation
Treat patients with
nursing intervention:
•Reorient patients
•Use patient`s
eyeglasses, hearing aids
•Familiarize
surroundings

30.  Indication: The patient can’t report by self due to consciousness change, sedation, artificial airway,
mechanical ventilation
 Assess: 2 fr ≥ duty, ASSESS
 intervention: 3 score ≥ CNPS, give pain killer.
 reevaluation:
Critical Care Nonverbal Pain Scale
Pain scale in
SNUH ICU
item tip score
day
time
1
Facial
expressio
n
Natural expression 0
tears 1
Painful expression 2
Biting endotracheal tube 3
2
Physical
response
No movement, relax 0
Slow motion 1
Nodding, try to touch painful site 2
Severe movement 3
3
Synchron
y with
ventilator
(intubate
d
patients)
No alarm sound,no cough 0
Intermittent alarm, cough, 1
Frequent alarm, hyperventilation 2
Asynchrony with ventilator, consistent cough 3
Voice
sound
(extubate
d
patients)
normal 0
moaning 1
Express about pain 2
Loud voice, Cry, aggressive 3
sum
Pain scale in
SNUH ICU

31. Education based on simulation
about unplanned extubation
Simulation training related to
unplanned extubation

32. I see you in ICU
Safety based nursing
A nurse will always give us hope, an angel with a
stethoscope.
~Terri Guillemets

33. References
• A. Rhodes, R. P. Moreno, E. Azoulay, M. Capuzzo, J. D. Chiche, J. Eddleston. et
al(2012). Prospectively defined indicators to improve the safety and quality of
care for critically ill patients: a report from the Task Force on Safety and
Quality of the European Society of Intensive Care Medicine (ESICM), Intensive Care
Med 38, 598–605.
• Atkins, P. M., Mion, L. C., Mendelson, W., Palmer, R. M., Slomka, J., & Franko, T.
(1997). Characteristics and outcomes of patients who selfextubate from ventilatory
support: A case- control study. Chest, 112(5),1317–1323.
• Curry, K., Cobb, S., Kutash, M., & Diggs, C(2008). Characteristics associated with
unplanned extubations in a surgical intensive care unit. American Journal of
Critical Care, 17(1), 45–51
• Da Silva, Lucas, Fonseca & Machado(2012). Unplanned extubation in the intensive
Care unit: systematic review, Critical Appraisal, and Evidence-Based
recommendations. Anesthesia & Analgesia, 114(5), 1003-1014.
• Juliana Barr, et al(2013). Clinical Practice Guidelines for the Ma- nagement of
pain, Agitation, and Delirium in Adult Patients in the intensive care unit.
Critical care medicine 41(1), 263-306.
• L-C Chang, P-F Liu, Y-L Huang, S-S Yang,W-Y Chang(2011). Risk factors associated
with unplanned endotracheal self extubation of hospitalized intubated patients: a
3-year re- trospective case-control study. Applied Nursing Research 24, 188–192.
• Mary Jarachovic, Maggie Mason, Kathleen Kerber & Molly McNett (2011). The role of
standardized protocols in unplanned extubations in a medical intensive care unit.
Am J Crit Care. 20, 304-312.

34. Thank you !! eunokkwon@nate.com